NACA Delegate Form

Name (as it appears on your driver's license)

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	First	Last	Item weight

SUPB Title

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	First	Last	Item weight

Birth Date

Cell Phone Number

Campus Address (or off-campus if commuter)

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

Are you willing to miss 3 days of classes (M, T & W)?

Please list any dietary restrictions:

List t-shirt size needed

Please describe your involvement in SUPB.

Why do you want to attend NACA? What do you hope to gain from the conference?

What do you think you would bring to the delegation? Why should we choose you to attend?

If selected to attend the conference I understand that if I back out of attending the conference after January 17, 2018, I may have to reimburse SUPB for the conference registration costs.

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